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Keystone 65 Select Medical Only (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Keystone 65 Select Medical Only (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Keystone 65 Select Medical Only (HMO) in 2025, please refer to our full plan details page.
Keystone 65 Select Medical Only (HMO) is a HMO plan offered by Independence Health Group, Inc. available for enrollment in 2025 to people living in Bucks, Philadelphia Counties. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Keystone 65 Select Medical Only (HMO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Keystone 65 Select Medical Only (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Keystone 65 Select Medical Only (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6000.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
Prescription drugs are not covered by Keystone 65 Select Medical Only (HMO).
Additional Benefits
The Keystone 65 Select Medical Only (HMO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay for the first few days, while outpatient services have copays for different services, such as $350 for outpatient hospital services. Emergency, primary care, and preventive services are covered, often with no copay, and the plan includes coverage for hearing, vision, and dental services, as well as home health and skilled nursing facility services. The plan covers ambulance services with a $225 copay, and covers durable medical equipment and dialysis services with coinsurance. Other benefits include coverage for home infusion bundled services, diagnostic and radiological services, and additional services like acupuncture, with some services subject to copays or coinsurance, and some services not covered at all.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, both of which require prior authorization. For the first 6 days of an Inpatient Hospital-Acute or Inpatient Hospital Psychiatric stay, there is a $275 copay, and days 7-90 have no copay. Additional days for Inpatient Hospital-Acute have no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, and additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a $350 copay, observation services with a $350 copay, ambulatory surgical center services with a $200 copay, and outpatient substance abuse services with a $30 copay for individual sessions and a $20 copay for group sessions. Outpatient blood services are also covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Keystone 65 Select Medical Only (HMO) plan, with a $30 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including both ground and air ambulance services, each with a $225 copay and no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Keystone 65 Select Medical Only (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, while Urgently Needed Services have a copay between $15 and $55; all have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Keystone 65 Select Medical Only (HMO) plan covers primary care physician services with no copay. Chiropractic services have a $20 copay, while occupational therapy services have a $20 copay.
Preventive Services See details
Preventive services include an annual physical exam with no copay, and other services such as Health Education, Medical Nutrition Therapy, Home-Based Palliative Care, Support for Caregivers of Enrollees, and Fitness Benefit with no copay. Other services such as In-Home Safety Assessment, Personal Emergency Response System (PERS), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Additional Sessions of Smoking and Tobacco Cessation Counseling, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered. Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit are covered with no copay.
Hearing Services See details
The Keystone 65 Select Medical Only (HMO) plan covers hearing exams for a $40 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $499 and $799, while prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay of $0-$40, and a routine eye exam with no copay. Eyewear is covered, with a combined maximum plan benefit coverage of $250 per year. Contact lenses and eyeglasses (lenses and frames) are covered, with a limit of one pair per year. However, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $40 copay, and other services including oral exams, dental x-rays, cleaning, and fluoride treatments with no copay, and restorative services with 20% coinsurance. Orthodontic services have a maximum benefit of $2000 per year. Maxillofacial Prosthetics and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. The plan covers Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Keystone 65 Select Medical Only (HMO) plan. You will pay 20% coinsurance.
Medical Equipment See details
The Keystone 65 Select Medical Only (HMO) plan covers Durable Medical Equipment (DME) with a 20% coinsurance and requires authorization. Prosthetics/Medical Supplies are covered with a 20% coinsurance for Medicare-covered items. Diabetic equipment is covered, with a 0-20% coinsurance for diabetic supplies and no copay for diabetic therapeutic shoes/inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic Procedures/Tests have no copay, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $200, Therapeutic Radiological Services have a copay of at most $80, and Outpatient X-Ray Services have a $40 copay.
Home Health Services See details
Home Health Services are covered by the Keystone 65 Select Medical Only (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Keystone 65 Select Medical Only (HMO) plan. The plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Keystone 65 Select Medical Only (HMO) plan with prior authorization required. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
The Keystone 65 Select Medical Only (HMO) plan covers acupuncture with a $20 copay, up to 6 treatments per year. Over-the-counter (OTC) items are also covered, with a maximum benefit of $30 every three months, but some services are not covered, including meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and others.
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